ADJUSTMENT REASON CODES REASON CODE DESCRIPTION - North Dakota

REASON CODE 1 2 3

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ADJUSTMENT REASON CODES DESCRIPTION Deductible Amount Coinsurance Amount Co-payment Amount The procedure code is inconsistent with the modifier used or a required modifier is missing. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

5

The procedure code/bill type is inconsistent with the place of service. Note: Refer to the 835

Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

6

The procedure/revenue code is inconsistent with the patient's age. Note: Refer to the 835

Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

7

The procedure/revenue code is inconsistent with the patient's gender. Note: Refer to the 835

Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

The procedure code is inconsistent with the provider type/specialty (taxonomy). Note: Refer to the

8

835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if

present.

The diagnosis is inconsistent with the patient's age. Note: Refer to the 835 Healthcare Policy

9

Identification Segment (loop 2110 Service Payment Information REF), if present.

The diagnosis is inconsistent with the patient's gender. Note: Refer to the 835 Healthcare Policy

10

Identification Segment (loop 2110 Service Payment Information REF), if present.

The diagnosis is inconsistent with the procedure. Note: Refer to the 835 Healthcare Policy

11

Identification Segment (loop 2110 Service Payment Information REF), if present.

The diagnosis is inconsistent with the provider type. Note: Refer to the 835 Healthcare Policy

12

Identification Segment (loop 2110 Service Payment Information REF), if present.

13

The date of death precedes the date of service.

14

The date of birth follows the date of service.

15

The authorization number is missing, invalid, or does not apply to the billed services or provider.

Claim/service lacks information which is needed for adjudication. At least one Remark Code must be

16

provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark

Code that is not an ALERT.)

Requested information was not provided or was insufficient/incomplete. At least one Remark Code

17

must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject

Reason Code.)

Duplicate claim/service. This change effective 1/1/2013: Exact duplicate claim/service (Use only with

18

Group Code OA)

19

This is a work-related injury/illness and thus the liability of the Worker's Compensation Carrier.

20

This injury/illness is covered by the liability carrier.

21

This injury/illness is the liability of the no-fault carrier.

22

This care may be covered by another payer per coordination of benefits.

23

The impact of prior payer(s) adjudication including payments and/or adjustments. (Use only with Group Code OA)

24

Charges are covered under a capitation agreement/managed care plan.

25

Payment denied. Your Stop loss deductible has not been met.

26

Expenses incurred prior to coverage.

27

Expenses incurred after coverage terminated.

28

Coverage not in effect at the time the service was provided.

29

The time limit for filing has expired.

Payment adjusted because the patient has not met the required eligibility, spend down, waiting, or

30

residency requirements.

31

Patient cannot be identified as our insured.

32

Our records indicate that this dependent is not an eligible dependent as defined.

33

Insured has no dependent coverage.

34

Insured has no coverage for newborns.

35

Lifetime benefit maximum has been reached.

36

Balance does not exceed co-payment amount.

37

Balance does not exceed deductible.

38

Services not provided or authorized by designated (network/primary care) providers.

39

Services denied at the time authorization/pre-certification was requested.

40

Charges do not meet qualifications for emergent/urgent care. Note: Refer to the 835 Healthcare

Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

41

Discount agreed to in Preferred Provider contract.

42

Charges exceed our fee schedule or maximum allowable amount. (Use CARC 45)

43

Gramm-Rudman reduction.

44

Prompt-pay discount.

Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. (Use

45

Group Codes PR or CO depending upon liability).

46

This (these) service(s) is (are) not covered.

47

This (these) diagnosis(es) is (are) not covered, missing, or are invalid.

48

This (these) procedure(s) is (are) not covered.

These are non-covered services because this is a routine exam or screening procedure done in

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conjunction with a routine exam. Note: Refer to the 835 Healthcare Policy Identification Segment

(loop 2110 Service Payment Information REF), if present.

These are non-covered services because this is not deemed a 'medical necessity' by the payer. Note:

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Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information

REF), if present.

51

These are non-covered services because this is a pre-existing condition. Note: Refer to the 835

Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the

52

service billed.

53

Services by an immediate relative or a member of the same household are not covered.

54

Multiple physicians/assistants are not covered in this case. Note: Refer to the 835 Healthcare Policy

Identification Segment (loop 2110 Service Payment Information REF), if present.

55

Procedure/treatment is deemed experimental/investigational by the payer. Note: Refer to the 835

Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Procedure/treatment has not been deemed 'proven to be effective' by the payer. Note: Refer to the

56

835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if

present.

57

Payment denied/reduced because the payer deems the information submitted does not support this

level of service, this many services, this length of service, this dosage, or this day's supply.

Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of

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service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment

Information REF), if present.

Processed based on multiple or concurrent procedure rules. (For example multiple surgery or

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diagnostic imaging, concurrent anesthesia.) Note: Refer to the 835 Healthcare Policy Identification

Segment (loop 2110 Service Payment Information REF), if present.

Charges for outpatient services are not covered when performed within a period of time prior to or

60

after inpatient services.

Penalty for failure to obtain second surgical opinion. Note: Refer to the 835 Healthcare Policy

61

Identification Segment (loop 2110 Service Payment Information REF), if present.

62

Payment denied/reduced for absence of, or exceeded, pre-certification/authorization.

63

Correction to a prior claim.

64

Denial reversed per Medical Review.

65

Procedure code was incorrect. This payment reflects the correct code.

66

Blood Deductible.

67

Lifetime reserve days. (Handled in QTY, QTY01=LA)

68

DRG weight. (Handled in CLP12)

69

Day outlier amount.

70

Cost outlier - Adjustment to compensate for additional costs.

71

Primary Payer amount.

72

Coinsurance day. (Handled in QTY, QTY01=CD)

73

Administrative days.

74

Indirect Medical Education Adjustment.

75

Direct Medical Education Adjustment.

76

Disproportionate Share Adjustment.

77

Covered days. (Handled in QTY, QTY01=CA)

78

Non-Covered days/Room charge adjustment.

79

Cost Report days. (Handled in MIA15)

80

Outlier days. (Handled in QTY, QTY01=OU)

81

Discharges.

82

PIP days.

83

Total visits.

84

Capital Adjustment. (Handled in MIA)

85

Patient Interest Adjustment (Use Only Group code PR)

86

Statutory Adjustment.

87

Transfer amount.

88

Adjustment amount represents collection against receivable created in prior overpayment.

89

Professional fees removed from charges.

90

Ingredient cost adjustment. Note: To be used for pharmaceuticals only.

91

Dispensing fee adjustment.

92

Claim Paid in full.

93

No Claim level Adjustments.

94

Processed in Excess of charges.

95

Plan procedures not followed.

Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the

96

NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if

present.

The benefit for this service is included in the payment/allowance for another service/procedure that

97

has already been adjudicated. Note: Refer to the 835 Healthcare Policy Identification Segment (loop

2110 Service Payment Information REF), if present.

98

The hospital must file the Medicare claim for this inpatient non-physician service.

99

Medicare Secondary Payer Adjustment Amount.

100

Payment made to patient/insured/responsible party/employer.

101

Predetermination: anticipated payment upon completion of services or claim adjudication.

102

Major Medical Adjustment.

103

Provider promotional discount (e.g., Senior citizen discount).

104

Managed care withholding.

105

Tax withholding.

106

Patient payment option/election not in effect.

107

The related or qualifying claim/service was not identified on this claim. Note: Refer to the 835

Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Rent/purchase guidelines were not met. Note: Refer to the 835 Healthcare Policy Identification

108

Segment (loop 2110 Service Payment Information REF), if present.

Claim/service not covered by this payer/contractor. You must send the claim/service to the correct

109

payer/contractor.

110

Billing date predates service date.

111

Not covered unless the provider accepts assignment.

112

Service not furnished directly to the patient and/or not documented.

Payment denied because service/procedure was provided outside the United States or as a result of

113

war.

114

Procedure/product not approved by the Food and Drug Administration.

115

Procedure postponed, canceled, or delayed.

116

The advance indemnification notice signed by the patient did not comply with requirements.

117

Transportation is only covered to the closest facility that can provide the necessary care.

118

ESRD network support adjustment.

119

Benefit maximum for this time period or occurrence has been reached.

120

Patient is covered by a managed care plan.

121

Indemnification adjustment - compensation for outstanding member responsibility.

122

Psychiatric reduction.

123

Payer refund due to overpayment.

124

Payer refund amount - not our patient.

125

Submission/billing error(s). At least one Remark Code must be provided (may be comprised of either

the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)

126

Deductible -- Major Medical

127

Coinsurance -- Major Medical

128

Newborn's services are covered in the mother's Allowance.

Prior processing information appears incorrect. At least one Remark Code must be provided (may be

129

comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not

an ALERT.)

130

Claim submission fee.

131

Claim specific negotiated discount.

132

Prearranged demonstration project adjustment.

The disposition of the claim/service is pending further review. (Use only with Group Code OA). Note:

133

Use of this code requires a reversal and correction when the service line is finalized ( use only in Loop

2110 CAS segment of the 835 or Loop 2430 of the 837).

134

Technical fees removed from charges.

135

Interim bills cannot be processed.

Failure to follow prior payer's coverage rules. (Use Group Code OA). This change effective 7/1/2013:

136

Failure to follow prior payer's coverage rules. (Use only with Group Code OA)

137

Regulatory Surcharges, Assessments, Allowances or Health Related Taxes.

138

Appeal procedures not followed or time limits not met.

139

Contracted funding agreement - Subscriber is employed by the provider of services.

140

Patient/Insured health identification number and name do not match.

141

Claim spans eligible and ineligible periods of coverage.

142

Monthly Medicaid patient liability amount.

143

Portion of payment deferred.

144

Incentive adjustment, e.g. preferred product/service.

145

Premium payment withholding

146

Diagnosis was invalid for the date(s) of service reported.

147

Provider contracted/negotiated rate expired or not on file.

Information from another provider was not provided or was insufficient/incomplete. At least one

148

Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or

Remittance Advice Remark Code that is not an ALERT.)

149

Lifetime benefit maximum has been reached for this service/benefit category.

150

Payer deems the information submitted does not support this level of service.

Payment adjusted because the payer deems the information submitted does not support this

151

many/frequency of services.

Payer deems the information submitted does not support this length of service. Note: Refer to the

152

835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if

present.

153

Payer deems the information submitted does not support this dosage.

154

Payer deems the information submitted does not support this day's supply.

155

Patient refused the service/procedure.

156

Flexible spending account payments. Note: Use code 187.

157

Service/procedure was provided as a result of an act of war.

158

Service/procedure was provided outside of the United States.

159

Service/procedure was provided as a result of terrorism.

160

Injury/illness was the result of an activity that is a benefit exclusion.

161

Provider performance bonus

State-mandated Requirement for Property and Casualty, see Claim Payment Remarks Code for

162

specific explanation.

163

Attachment referenced on the claim was not received.

164

Attachment referenced on the claim was not received in a timely fashion.

165

Referral absent or exceeded.

These services were submitted after this payers responsibility for processing claims under this plan

166

ended.

This (these) diagnosis(es) is (are) not covered. Note: Refer to the 835 Healthcare Policy Identification

167

Segment (loop 2110 Service Payment Information REF), if present.

Service(s) have been considered under the patient's medical plan. Benefits are not available under

168

this dental plan.

169

Alternate benefit has been provided.

170

Payment is denied when performed/billed by this type of provider. Note: Refer to the 835

Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Payment is denied when performed/billed by this type of provider in this type of facility. Note: Refer

171

to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if

present.

172

Payment is adjusted when performed/billed by a provider of this specialty. Note: Refer to the 835

Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Service was not prescribed by a physician. This change effective 7/1/2013: Service/equipment was

173

not prescribed by a physician.

174

Service was not prescribed prior to delivery.

175

Prescription is incomplete.

176

Prescription is not current.

177

Patient has not met the required eligibility requirements.

178

Patient has not met the required spend down requirements.

Patient has not met the required waiting requirements. Note: Refer to the 835 Healthcare Policy

179

Identification Segment (loop 2110 Service Payment Information REF), if present.

180

Patient has not met the required residency requirements.

181

Procedure code was invalid on the date of service.

182

Procedure modifier was invalid on the date of service.

183

The referring provider is not eligible to refer the service billed. Note: Refer to the 835 Healthcare

Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

The prescribing/ordering provider is not eligible to prescribe/order the service billed. Note: Refer to

184

the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if

present.

185

The rendering provider is not eligible to perform the service billed. Note: Refer to the 835 Healthcare

Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

186

Level of care change adjustment.

Consumer Spending Account payments (includes but is not limited to Flexible Spending Account,

187

Health Savings Account, Health Reimbursement Account, etc.)

188

This product/procedure is only covered when used according to FDA recommendations.

'Not otherwise classified' or 'unlisted' procedure code (CPT/HCPCS) was billed when there is a

189

specific procedure code for this procedure/service

190

Payment is included in the allowance for a Skilled Nursing Facility (SNF) qualified stay.

Not a work related injury/illness and thus not the liability of the workers' compensation carrier Note:

If adjustment is at the Claim Level, the payer must send and the provider should refer to the 835

191

Insurance Policy Number Segment (Loop 2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the payer must send and the provider

should refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment

information REF)

Non standard adjustment code from paper remittance. Note: This code is to be used by

192

providers/payers providing Coordination of Benefits information to another payer in the 837

transaction only. This code is only used when the non-standard code cannot be reasonably mapped

to an existing Claims Adjustment Reason Code, specifically Deductible, Coinsurance and Co-payment.

193

Original payment decision is being maintained. Upon review, it was determined that this claim was

processed properly.

194

Anesthesia performed by the operating physician, the assistant surgeon or the attending physician.

195

Refund issued to an erroneous priority payer for this claim/service.

196

Claim/service denied based on prior payer's coverage determination.

197

Precertification/authorization/notification absent.

198

Precertification/authorization exceeded.

199

Revenue code and Procedure code do not match.

200

Expenses incurred during lapse in coverage

Patient is responsible for amount of this claim/service through 'set aside arrangement' or other

201

agreement. ( Use only with Group Code PR) At least on remark code must be provider (may be comprised of either the NCPDP Reject Reason Code or Remittance Advice Remark Code that is not

an alert.)

202

Non-covered personal comfort or convenience services.

203

Discontinued or reduced service.

204

This service/equipment/drug is not covered under the patients current benefit plan

205

Pharmacy discount card processing fee

206

National Provider Identifier - missing.

207

National Provider identifier - Invalid format

208

National Provider Identifier - Not matched.

Per regulatory or other agreement. The provider cannot collect this amount from the patient.

However, this amount may be billed to subsequent payer. Refund to patient if collected. (Use Group

209

code OA) This change effective 7/1/2013: Per regulatory or other agreement. The provider cannot

collect this amount from the patient. However, this amount may be billed to subsequent payer.

Refund to patient if collected. (Use only with Group code OA)

210

Payment adjusted because pre-certification/authorization not received in a timely fashion

211

National Drug Codes (NDC) not eligible for rebate, are not covered.

212

Administrative surcharges are not covered

213

Non-compliance with the physician self referral prohibition legislation or payer policy.

Workers' Compensation claim adjudicated as non-compensable. This Payer not liable for claim or

service/treatment. Note: If adjustment is at the Claim Level, the payer must send and the provider

214

should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related

Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the

payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment

(loop 2110 Service Payment information REF). To be used for Workers' Compensation only

215

Based on subrogation of a third party settlement

216

Based on the findings of a review organization

217

Based on payer reasonable and customary fees. No maximum allowable defined by legislated fee

arrangement. (Note: To be used for Property and Casualty only)

Based on entitlement to benefits. Note: If adjustment is at the Claim Level, the payer must send and

the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim

218

Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line

Level, the payer must send and the provider should refer to the 835 Healthcare Policy Identification

Segment (loop 2110 Service Payment information REF). To be used for Workers' Compensation only

Based on extent of injury. Note: If adjustment is at the Claim Level, the payer must send and the

provider should refer to the 835 Insurance Policy Number Segment (Loop 2100 Other Claim Related

219

Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at the Line Level, the

payer must send and the provider should refer to the 835 Healthcare Policy Identification Segment

(loop 2110 Service Payment information REF).

The applicable fee schedule/fee database does not contain the billed code. Please resubmit a bill

220

with the appropriate fee schedule/fee database code(s) that best describe the service(s) provided

and supporting documentation if required. (Note: To be used for Property and Casualty only)

Workers' Compensation claim is under investigation. Note: If adjustment is at the Claim Level, the

payer must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop

2100 Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If

adjustment is at the Line Level, the payer must send and the provider should refer to the 835

Healthcare Policy Identification Segment (loop 2110 Service Payment information REF). This change

221

effective 7/1/2013: Claim is under investigation. Note: If adjustment is at the Claim Level, the payer

must send and the provider should refer to the 835 Insurance Policy Number Segment (Loop 2100

Other Claim Related Information REF qualifier 'IG') for the jurisdictional regulation. If adjustment is at

the Line Level, the payer must send and the provider should refer to the 835 Healthcare Policy

Identification Segment (loop 2110 Service Payment information REF). (Note: To be used by Property

& Casualty only)

Exceeds the contracted maximum number of hours/days/units by this provider for this period. This is

222

not patient specific. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110

Service Payment Information REF), if present.

Adjustment code for mandated federal, state or local law/regulation that is not already covered by

223

another code and is mandated before a new code can be created.

Patient identification compromised by identity theft. Identity verification required for processing this

224

and future claims.

225

Penalty or Interest Payment by Payer (Only used for plan to plan encounter reporting within the 837)

Information requested from the Billing/Rendering Provider was not provided or was

insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either

the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) This

226

change effective 7/1/2013: Information requested from the Billing/Rendering Provider was not

provided or not provided timely or was insufficient/incomplete. At least one Remark Code must be

provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark

Code that is not an ALERT.)

Information requested from the patient/insured/responsible party was not provided or was

227

insufficient/incomplete. At least one Remark Code must be provided (may be comprised of either

the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)

228

Denied for failure of this provider, another provider or the subscriber to supply requested

information to a previous payer for their adjudication

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